Hostname: page-component-586b7cd67f-vdxz6 Total loading time: 0 Render date: 2024-11-26T14:29:27.110Z Has data issue: false hasContentIssue false
  • English
  • Français

Special Ethical Issues in the Management of PVS Patients

Published online by Cambridge University Press:  29 April 2021

Baruch Brody
Get access Rights & Permissions [Opens in a new window]

Extract

The patient in a persistent vegetative state (hereafter, the PVS patient) has played a central role in recent American bioethical discussions and in recent litigation involving bioethical issues. From Quinlan’ to Cruzan and Wanglie, some of the most important cases involving ethical issues at the end of life have involved PVS patients. Major American medical groups such as the AMA and the American Academy of Neurology have adopted important policy statements on the care of such patients, statements that have been followed by at least one European group.

I have always found this activity a bit of a mystery. There is, after all, a relatively clear consensus about decision-making at the end of life, a consensus embodied in such documents as a report from the President's Commission and a report from the Hastings Center.

Type
Article
Information
Law, Medicine and Healthcare , Volume 20 , Issue 1-2 , Spring Summer 1992 , pp. 104 - 115
Copyright
Copyright © American Society of Law, Medicine and Ethics 1992

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

In re Quinlan 70 NJ 10, 355 A2d 647 (1976).Google Scholar
Cruzan v. Director, Missouri Department of Health 58 LW 4916.Google Scholar
In re the Conservatorship of Helga M. Wanglie, State of Minnesota, County of Hennepin, District Court-Probate Court Division, Fourth Judicial District File No. PX-91-283.Google Scholar
Council on Scientific Affairs and Council on Ethical and Judicial Affairs, “Persistent Vegetative State and the Decision to Withdraw or Withhold Life Support,” JAMA 1990; 263(3): 426–30.Google Scholar
“Position of the American Academy of Neurology on certain aspects of the care and management of the persistent vegetative state patient,” Neurology 1989; 39: 125–6.CrossRefGoogle Scholar
Institute of Medical Ethics Working Party, “Withdrawal of Life-Support from Patients in a Persistent Vegetative State, The Lancet 1991; 337: 96–8.Google Scholar
President's Commission for the Study of Ethical Problems in Medicine, Deciding to Forego Life-Sustaining Treatment, Washington DC; Government Printing Office:1983.Google Scholar
Guidelines on the Termination of Life-Sustaining Treatment and the Care of the Dying, Hastings-on-Hudson, New York: The Hastings Center; 1987.Google Scholar
Cranford, R.E., “The Persistent Vegetative State: The Medical Reality (Getting the Facts Straight),” Hastings Center Report 1988; 18(1): 27–32.CrossRefGoogle Scholar
Levy, D.E., Sidtis, J.J., Rottenberg, D.A., et al., “Differences in Cerebral Blood Flow and Glucose Utilization in Vegetative versus Locked-In Patients,” Annals of Neurology 1987; 22(6): 673–82.Google Scholar
Uniform Determination of Death Act, 12 ULA 320 (1990 supp.).Google Scholar
Engelhardt, H.T., The Foundations of Bioethics, New York; Oxford University Prcss:1986; Smith, D. “Legal Recognition of Neocortical Death,” Cornell Law Review 1986;71:850–88, Youngner, S.J. and Bartlett, E.T., “Human Death and High Technology,” Annals of Internal Medicine 1983;99:252–8, and Veatch, R.M., “The Whole-Brain-Oriented Concept of Death: An Outmoded Philosophical Foundation,” Journal of Thanatology 1975;3:13-30.Google Scholar
Green, M. and Wikler, D., “Brain Death and Personal Identity,” Philosophy and Public Affairs, 1980;9:105–33.Google Scholar
President's Commission fot the Study of Ethical Problems in Medicine, Defining Death, Washington, D.C.: Government Printing Office; 1981.Google Scholar
Ibid.Google Scholar
Brody, B.A., “The President's Commission: The Need to be More Philosophical,” Journal of Medicine and Philosophy 1989; 14(4):369–83.Google Scholar
Zadeh, L., “Fuzzy Sets,” Information and Control 1965; 8:338–53.Google Scholar
Halevy, A. and Brody, B.A., “Brain Death.” Submitted for publication.Google Scholar
Supra note 5, p. 123.Google Scholar
Supra note 4, p. 429.Google Scholar
See the citations in footnote 6 and the surrounding text in Cruzan, supra note 2.Google Scholar
Ibid p. 4920.Google Scholar
Callahan, D., “On Feeding the Dying,” Hastings Center Report 1983;13(5):22.CrossRefGoogle Scholar
May, W.E., Barry, R., Griese, O., et al., “Feeding and Hydrating the Permanently Unconscious and Other Vulnerable Persons,” Issues in Law and Medicine 1987; 3(3):203–17.Google Scholar
Two prominent recent discussions are Quill, T.E., “Death and Dignity,” New England Journal of Medicine, 1991;324(10):691–4 and Institute of Medical Ethics Working Party, “Assisted Death,” The Lancet, 1990;336:610–3.Google Scholar
Ibid. p. 613.Google Scholar
See, for example, the data presented in Bedell, S.E. and Delbanco, T.L., “Choices about Cardiopulmonary Resuscitation in the Hospital,” New England Journal of Medicine 1984; 310(17): 1089–93 and in Evans, A.L. and Brody, B.A., “The Do-Not-Resuscitate Order in Teaching Hospitals,” JAMA 1985; 253(15):2236–9.Google Scholar
Among them are Brett, A.S. and McCullough, L.B., “When Patients Request Specific Interventions,” New England Journal of Medicine 1986; 315:1347–51; Blackhall, L.J., “Must We Always Use CPR?” New England Journal of Medicine 1987; 317:1281–5; Tomlinson, T. and Brody, H., “Ethics and Communication in Do-Not-Resuscitate Orders,” New England Journal of Medicine 1988; 318: 43–6; and Murphy, D.J., “Do-Not-Resuscitate Orders: Time for Reappraisal in Long-Term-Care Institutions,” JAMA 1988; 260:2098-2101.CrossRefGoogle Scholar
Schneiderman, L.J., Jecker, N.S. and Jonsen, A.R., “Medical Futility: Its Meaning and Ethical Implications,” Annals of Internal Medicine 1990; 112(12):949–54.Google Scholar
Ibid.Google Scholar
Ibid.Google Scholar
Ibid.Google Scholar
Council on Ethical and Judicial Affairs “Guidelines for the Appropriate Use of Do-Not-Resuscitate Orders,” JAMA 1991; 265(14):1868–71.CrossRefGoogle Scholar
One of the most prominent of which is Pellegrino, E. and Thomasma, D., For the Patient's Good, New York; Oxford University Press: 1988.Google Scholar
Miles, S., “Memo to Interested Medical Ethicists,” (unpublished document dated May 15, 1991).Google Scholar
Ibid.Google Scholar
Engelhardt, H.T., Bioethics and Secular Humanism, New York; Oxford University Press: 1991. p. 136.Google Scholar
Jonsen, A.R., Siegler, M. and Winslade, W.J., Clinical Ethics, Macmillan; New York: 1982, pp. 13–14.Google Scholar
Two important criticisms, from very different perspectives, are Harmon, L., “Falling Off the Vine: Legal Fictions and the Doctrine of Substituted Judgment,” Yale Law Journal, 1990; 100(1):1–71, and Dresser, R.S. and Robertson, J.A., “Quality of Life and Non-Treatment Decisions for Incompetent Patients: A Critique of the Orthodox Approach,” Law, Medicine and Health Care 1989; 17(3):234–44.Google Scholar
Buchanan, A.E. and Brock, D., Deciding for Others, Cambridge University Press; New York:1989 pp.127–8.Google Scholar
Supra note 5, p. 126.Google Scholar
The reasons for this emerge in Part I of Griffin, J. Well-Being, Oxford University Press; Oxford: 1986.Google Scholar
Brandt, R. “Two Concepts of Utility,” chapter 10 of Miller, H.B. and Williams, W.H. (eds.) The Limits of Utilitarianism, University of Minnesota; Minneapolis: 1982. p. 172.Google Scholar
Supra note 40, pp. 165–6.Google Scholar
Supra note 35, p. 13.Google Scholar
Harsanyi, J.C., “Morality and the Theory of Rational Behavior,” chapter 2. of Sen, A. and Williams, B. (eds.) Utilitarianism and Beyond. Cambridge University Press; Cambridge: 1982. p.55.Google Scholar
Supra note 14.Google Scholar
Brody, B.A., Life and Death Decision Making. New York; Oxford University Press; 1989.Google Scholar
Such a view is expressed in Committee on Medical Ethics, The Compendium on Medical Ethics, 6th. ed. New York; Federation of Jewish Philanthropies: 1984.Google Scholar
An important recent statement of that view is Angell, M., “Cost Containment and the Physician,” JAMA 1985; 254(9):1203–7. The classic statement is Fried, C., “Rights and Health—Beyond Equity and Efficiency,” NEJM 1975;293(5):241–5.Google Scholar